PUBLIC DISPLAY OF FIREWORKS PERMIT APPLICATION PROPERTY OWNER/MANAGER INFORMATION Must Be Filed 30 Days in Advance of Event

Transcription

1 Page 1 Name of Applicant: PROPERTY OWNER/MANAGER INFORMATION Must Be Filed 30 Days in Advance of Event Current Address: City: State: Zip: Phone: Fax: BUSINESS / ORGANIZATION INFORMATION Type of Business: Corporation Partnership Sole Proprietorship LLC Non-Profit Business Name: LIST OF OFFICERS INSURANCE INFORMATION Name of Carrier: Amt. of Coverage: EVENT INFORMATION Type of Event: Date/Hours of Event: Location of Event: INFORMATION OF PERSON SPONSORING EVENT Name: Phone: AFFIDAVIT AN AFFIDAVIT SWORN TO BY THE PROPERTY MANAGER, SPONSOR AND OWNER/OPERATOR OF THE CERTIFYING TO COMPLIANCE WITH ARTICLE 405 OF NYS PENAL LAW AND THE NOISE ORDINANCE OF THE CITY OF NEW ROCHELLE. THAT THE ACTUAL POINT AT WHICH THE FIREWORKS ARE TO BE FIRED SHALL BE AT LEAST 200 FEET FROM THE NEAREST PERMANENT BUILDING, PUBLIC HIGHWAY OR RAILROAD OR OTHER MEANS OF TRAVEL AND AT LEAST 50 FEET FROM THE NEAREST ABOVE GROUND TELEPHONE OR TELEGRAPH LINE, TREE OR OTHER OVERHEAD OBSTRUCTION AND THE AUDIENCE MUST BE AT LEAST 150 FEET FROM THE POINT OF FIREWORKS DISCHARGE. SIGNATURES I hereby acknowledge that the sponsor of the stated event has authorized the mentioned Fireworks Display Company to produce said display on our property with due observance of all laws and regulations governing same by Article 405 of the NYS Penal Law and the noise ordinance in the City of New Rochelle. Signature of Applicant: Signature of Sponsor: Sworn and Subscribed to Before Me: Address: This day of, 20 NOTARY OR COMMISSIONER OF DEEDS Seal:

2 Page 2 AFFIDAVIT ATTACHED TO APPLICATION FOR FIREWORKS DISPLAY PROPERTY OWNER & SPONSOR STATE OF NEW YORK ) COUNTY OF WESTCHESTER) ss.: The undersigned, Property Owner and/or Manager of said property and Sponsor of said event, described on the application to which this is attached, certifies that the Sponsor has entered into a contract for the described event and we will operate, in full compliance with the Regulations of Article 405 of the NYS Penal Law and all the laws and ordinances of the City of New Rochelle that govern Fireworks Display, Noise Control and any other regulations of the New Rochelle Fire Department and New Rochelle Police Department. Sworn to before me this day of 20 Notary Public Property Owner Event Sponsor Notary Seal:

3 Page 3 Name of Applicant: OPERATOR INFORMATION Must be Filed 30 Days in Advance of Event Current Address: City: State: Zip: Date of Birth: Phone: Drivers License #: BUSINESS / ORGANIZATION INFORMATION Type of Business: Corporation Partnership Sole Proprietorship LLC Non-Profit Business Name: LIST OF OFFICERS INSURANCE INFORMATION Name of Carrier: Amt. of Coverage: Note: City of New Rochelle and the property owner must be listed as Additional Insured with an Endorsement. The minimum requirements are $3,000,000 for property damage and $5,000,000 for personal injuries for each accident. Insurance Certificate and Endorsement Must Be Attached. EVENT INFORMATION Type of Event: Date of Event: Time of Event: Note: The Fireworks Display must conclude no later than 10:00 PM. Type of Fireworks Display: Exact Location of Fireworks Display: TYPES OF FIREWORKS TO BE DISPAYED Number of Fireworks: Disposition of Unfired Shells: Note: A permit from the Coast Guard must be submitted with this application as well as a diagram of the grounds locating buildings, trees and other obstructions. Audience must be at least 150 feet from the discharge of the fireworks. FIREWORKS DISPLAY OPERATER(S) SIGNATURES I hereby apply for a permit for a fireworks display, and bind myself and my principal to the due observance of Article 405 of the NYS Penal Law and all laws and regulations governing same in the City of New Rochelle and further certify that no judgments for goods or services are outstanding against us. Signature of Applicant: Sworn and Subscribed to Before Me: Address: This day of, 20 Seal:

4 Page 4 AFFIDAVIT ATTACHED TO APPLICATION FOR FIREWORKS DISPLAY FIREWORKS DISPLAY OPERATOR & PROPERTY OWNER STATE OF NEW YORK ) COUNTY OF WESTCHESTER) ss.: The undersigned, Fireworks Display Operator of said company on the application to which this is attached, certifies that we have entered into a contract with the property owner and sponsor, and we will operate, in full compliance with the Regulations of Article 405 of the NYS Penal Law and all the laws and ordinances of the City of New Rochelle that govern Fireworks Display, Noise Control and regulations of the New Rochelle Fire Department and New Rochelle Police Department. Sworn to before me this day of 20 Notary Public Fireworks Display Operator Property Owner Notary Seal:

5 Page 5 City of New Rochelle Authorizations PERMITS ARE GRANTED TO THE FIREWORKS DISPLAY COMPANY. NO RAIN DATES WILL BE GRANTED. 1. FINANCE/RISK MANAGEMENT I have examined the public liability insurance policy covering the fireworks display company and naming the City of New Rochelle as additional insured with an endorsement and minimum coverage of $3,000,000 for property damage and $5,000,000 for personal injuries as provided by the Code of the City of New Rochelle, NY. 2. CORPORATION COUNSEL I have examined the application and its compliance to the New York State Penal Law Article 405 and the presentation of proof of liability insurance naming the City as additional insured with an endorsement as required by the Code of the City of New Rochelle, NY. 3. FIRE DEPARTMENT I have examined the location designated and the site plan, accordingly, it would not be hazardous to surrounding property or persons. I have inspected the Fireworks Equipment and area for the Fireworks Display which conforms to Article 405 of the NYS Penal Law, and all laws and ordinances of the City of New Rochelle. 4. POLICE DEPARTMENT I have examined the location and the site plans described in this application and certify that it complies with the requirements of the New Rochelle Police and Fire Departments for the safety of persons using this devise and the audience of this event. 5. PARKS & RECREATION DEPARTMENT I have reviewed this application and the site plan with the Harbormaster and in the area of the intended event. 6. CITY MANAGER The foregoing application is approved, and the City Clerk is hereby directed to issue a Public Fireworks Display Permit for a fee of $1, as provided in the Code of the City of New Rochelle, NY. License No. Base Fee: $1, CITY CLERK Fireworks display must end by 10 PM on Date of Event. Additional fees may apply by required event inspections. (City Seal)